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With the development and improvement of enhanced recovery after surgery protocol over the past 20 years, there is an increasing acceptance and application of enhanced recovery after surgery in many surgical subspecialties. Thoracic surgery has also started adopting the practice of enhanced recovery after surgery, and some hospitals have already implemented elements of enhanced recovery after surgery pertinent to thoracic surgical patients such as optimization of preoperative pulmonary rehabilitation, increasing application of regional anesthesia in multimodal analgesia, single chest tube placement, and early removal of chest tube. Enhanced recovery in thoracic surgery has resulted some improved clinical outcomes with multidisciplinary multimodal perioperative approach.

Peripartum cardiomyopathy is a rare form of heart failure with significant perioperative implications. In this case report, we describe a 34-year-old gravida 5, parity 3, patient who was admitted for an elective cesarean delivery. During the delivery, the patient developed sudden cardiac arrest and was emergently intubated in the operating room. An emergent transesophageal echocardiogram revealed a left ventricular ejection fraction of 10% with global biventricular hypokinesis. Urgent multidisciplinary consultations led to the rapid implementation of the Impella™ 2.5 for ventricular support. The patient recovered ventricular function within 4 days and recovered to baseline function.

BACKGROUND: There is still controversy regarding the optimal strategy for managing postoperative nausea and vomiting (PONV) in high-risk surgical populations. Although acustimulation at the P6 acupoint has been demonstrated to be effective in preventing PONV, the effect of this nonpharmacologic therapy on the patient’s recovery with respect to resumption of normal activities of daily living has not been previously assessed when it is used as part of a multimodal antiemetic regimen. Therefore, we designed this randomized, sham-controlled, and double-blind study to assess the efficacy of a disposable acupressure device (Pressure Right�; Pressure Point Inc., Grand Rapids, MI) on the incidence of emetic episodes and quality of recovery when used in combination with ondansetron and dexamethasone for antiemetic prophylaxis. METHODS: One hundred ASA physical status I and II patients undergoing major laparoscopic procedures were randomly assigned to either a control group (n 50) receiving a “sham” acustimulation device or an acupressure group (n 50) receiving a disposable Pressure Right device placed bilaterally at the P6 point 30 to 60 minutes before induction of anesthesia. All patients received a standardized general anesthetic. A combination of ondansetron, 4 mg IV, and dexamethasone, 4 mg IV, was administered during surgery for antiemetic prophylaxis in both study groups. The incidence of nausea and vomiting and the need for “rescue” antiemetic therapy were assessed at specific time intervals for up to 72 hours after surgery. The recovery profiles and quality of recovery questionnaires were evaluated at 48 hours and 72 hours after surgery. Patient satisfaction with the management of their PONV was assessed at the end of the 72-hour study period. RESULTS: The 2 study groups did not differ in their demographic characteristics or risk factors for PONV. The incidence of vomiting at 24 hours was significantly decreased in the acupressure group (10% vs 26%, P 0.04, 95% confidence interval for absolute risk reduction 1%–31%). The overall incidence of vomiting from 0 to 72 hours after surgery was also significantly decreased from 30% to 12% in the acupressure group (P 0.03, 95% confidence interval 2%–33%). Furthermore, adjunctive use of the acupressure device seemed to enhance patient satisfaction with their PONV management and quality of recovery at 48 hours after surgery. However, the recovery times to hospital discharge, resumption of normal physical activities, and return to work did not differ significantly between the 2 study groups. CONCLUSION: Use of the Pressure Right acupressure device in combination with antiemetic drugs provided a reduction in the incidence of vomiting from 0 to 72 hours after surgery with an associated improvement in patient satisfaction with their PONV management. However, recovery and outcome variables failed to demonstrate any improvement with the addition of the acupressure device. (Anesth Analg 2012;X:●●●–●●●)

BACKGROUND: Nonsteroidal antiinflammatory drugs have become increasingly popular as part of multimodal analgesic regimens for pain management in the ambulatory setting. We designed this randomized, double-blind, placebo-controlled study to evaluate the effect of postoperative administration of either a nonselective nonsteroidal antiinflammatory drug (ibuprofen) or the cyclooxygenase-2 selective inhibitor (celecoxib when administered as part of a multimodal analgesic regimen) on the severity of pain, the need for rescue analgesics, and clinically relevant patient outcomes after ambulatory surgery. The primary end point was the time to resumption of normal activities of daily living. METHODS: One hundred eighty patients undergoing outpatient surgery were randomly assigned to 1 of 3 treatment groups: group 1 (control) received either 2 placebo capsules (matching celecoxib) or 1 placebo tablet (matching ibuprofen) in the recovery room and 1 placebo tablet at bedtime on the day of surgery, followed by 1 placebo capsule or tablet 3 times a day for 3 days after discharge; group 2 (celecoxib) received celecoxib 400 mg (2 capsules) orally in the recovery room and 1 placebo capsule and tablet at bedtime on the day of surgery, followed by celecoxib 200 mg (1 capsule) twice a day + placebo capsule every day at bedtime for 3 days after surgery; or group 3 (ibuprofen) received ibuprofen 400 mg (1 tablet) orally in the recovery room and 400 mg orally at bedtime on the day of surgery, followed by 400 mg orally 3 times a day for 3 days after surgery. Recovery times, postoperative pain scores, and the need for rescue analgesics were recorded before discharge. Follow-up evaluations were performed at 24 hours, 48 hours, 72 hours, 7 days, and 30 days after surgery to assess postdischarge pain, analgesic requirements, resumption of normal activities, opioid-related side effects, as well as quality of recovery and patient satisfaction with their postoperative pain management using a 5-point verbal rating scale. RESULTS: The 3 groups did not differ with respect to their demographic characteristics. Compared with the placebo treatment, both celecoxib and ibuprofen significantly decreased the need for rescue analgesic medication after discharge (P < 0.05). The effect sizes (celecoxib and ibuprofen versus control group) were 0.73 to 1 and 0.3 to 0.8, respectively. Quality of recovery scores and patient satisfaction with their postoperative pain management were also improved in the celecoxib and ibuprofen groups compared with the control group (P < 0.05, effect size [vs control group] = 0.67). The incidence of postoperative constipation was significantly higher in the control group (28%) compared with the celecoxib (5%) and ibuprofen (7%) groups, respectively (P < 0.05). Both active treatments were well tolerated in the postdischarge period. However, the time to resumption of normal activities of daily living was similar among the 3 groups. CONCLUSIONS: Both ibuprofen (1200 mg/d) and celecoxib (400 mg/d) significantly decreased the need for rescue analgesic medication in the early postdischarge period, leading to an improvement in the quality of recovery and patient satisfaction with their pain management after outpatient surgery.

This study conducts a social semiotic analysis of the online city guide of Guangzhou. Drawing on Martin’s Appraisal theory with a particular focus on the semantic systems of attitude and graduation, this paper investigates the attitudinal meanings adjusted by graduation in both modes of language and visual images. It is revealed that positive appreciation resources are dominant among the three subsystems of attitude, with the pervasive use of reaction and valuation resources to stimulate tourist desires and promote unique identity of the city. Graduation resources, especially force, couple with attitude resources to upscale the positivity of the attitude and strongly align the readers into the same value position. The language and images in most cases coordinate with each other, with the evaluative meanings of visual images elaborating or extending those of verbal texts, whereas complementary intermodal relation exists in some cases, with the evaluative meanings conveyed by visual images and the verbal texts merely offering factual information. The findings may help to better understand the way online city guides achieve the communicative purposes through multimodal evaluative devices.

We evaluated the cognitive recovery profiles in elderly patients after general anesthesia with desflurane or sevoflurane. After IRB approval, 70 ASA physical status I-III consenting elderly patients (or =65 yr old) undergoing total knee or hip replacement procedures were randomly assigned to one of two general anesthetic groups. Propofol and fentanyl were administered for induction of anesthesia, followed by either desflurane 2%-4% or sevoflurane 1%-1.5% with nitrous oxide 65% in oxygen. The desflurane (2.5 +/- 0.6 MAC. h) and sevoflurane (2.7 +/- 0.5 MAC. h) concentrations were adjusted to maintain comparable depths of hypnosis using the electroencephalogram bispectral index monitor. The Mini-Mental State (MMS) test was used to assess cognitive function preoperatively and postoperatively at 1, 3, 6, and 24-h intervals. The use of desflurane was associated with a more rapid emergence from anesthesia (6.3 +/- 2.4 min versus 8.0 +/- 2.8 min) and a shorter length of stay in the postanesthesia care unit (213 +/- 66 min versus 241 +/- 87 min). However, there were no significant differences between the Desflurane and the Sevoflurane groups when the MMS scores were compared preoperatively, and postoperatively at 1, 3, 6, and 24 h. Compared with the preoperative (baseline) MMS scores, the values were significantly decreased at 1 h postoperatively (27.8 +/- 1.7 versus 29.5 +/- 0.5 in the Desflurane group, and 27.4 +/- 1.7 versus 29.2 +/- 1.0 in the Sevoflurane group, respectively). However, the MMS scores returned to preoperative baseline levels within 6 h after surgery. At 1 h and 3 h after surgery, 51% and 11% (versus 57% and 9%) of patients in the Desflurane (versus Sevoflurane) Group experienced cognitive impairment. In conclusion, desflurane is associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar after desflurane and sevoflurane-based anesthesia.Desflurane was associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar with both volatile anesthetics.

The anesthetic management of patients undergoing cardiac surgery on cardiopulmonary bypass can be challenging. Contact of blood with extracorporeal surfaces results in altered coagulational integrity and increased risk of bleeding. Patients with preexisting bleeding disorders are particularly vulnerable. In this article we discuss the anesthetic management of a patient with von Willebrand disease (vWD) undergoing mitral valve replacement on cardiopulmonary bypass. vWD describes a number of different von Willebrand factor disorders, associated with variable degrees of bleeding, which require an individualized approach. The extent of the surgery, the patient-specific vWD coagulopathy, and clinical indicators guided our therapy, which included desmopressin, cryoprecipitate, and vWF/Factor VIII concentrate.

The case of a 61 year-old male with recurrent retinal detachment who experienced a systole after increasing intraocular pressure through the sclerotomy infusion cannula during vitrectomy is reported. While the oculocardiac reflex is well-know, this case is unique as neither direct ocular compression nor extraocular muscle traction was present when the incident occurred. When any structure innervated by the trigeminal nerve is manipulated, vigilance should be maintained as this potentially fatal reflex can successfully be treated and prevented.

Objective To assess the usefulness of fluorescence in situ hybridization (FISH) for HER-2/neu amplification of breast carcinoma in archival fine needle aspiration biopsy (FNAB) specimens. Study Design All FISH performed on formalin-fixed, paraffin-embedded surgical specimens during January 2003-August 2003 at the University of California Irvine Medical Center were selected. Prior FNABs were retrieved. One cytologic slide was destained in each case. The results were compared with those obtained on histologic specimens using the paired t test. Results FISH was performed on 41 surgical specimens of breast carcinoma. Thirteen patients had prior FNABs that -mere positive for adenocarcinoma. After hybridization on destained fine needle aspiration slides, no cells were found in 2 cases, and the results were not readable in 2 cases. In the remaining 9 cases, the results, expressed as the ratio of copies of the HER-2/neu gene to copies of the chromosome 17 centromere, were 5.10, 1.14, 1.21, 1.12, 0.74, 1.11, 1.21, 9.87 and 2.4. Results on the corresponding histologic specimens were 5.23, 1.03, 1.13, 1.22, 1.13, 1.12, 1.21, 9.35 and 2.61, respectively. No significant difference was found (p = 0.23). Conclusion HER-2/neu amplification status by FISH can be accurately and reliably evaluated in existing archival cytologic slides.